Anticipated Impacts on Veterans Health Care: By examining the impact of dual health care system use (dual use) and other factors among Veterans with heart failure (HF), the VA will better understand determinants of increased healthcare utilization and poor patient outcomes in this population. This study will lead directly to the development of systems-level interventions to improve care quality for Veterans with HF, while focusing on priority VA research areas of access to care and chronic disease management in an operationally relevant manner. Background: HF is a serious health condition currently affecting 5.8 million Americans and is associated with high 30-day (10.4%) mortality after hospitalization. HF causes 1.1 million hospitalizations and 3.4 million ambulatory care visits each year at an estimated cost of $39.2 billion. Among Veterans, it is the most frequent cause for hospital admission and one of the most frequent causes of unplanned hospital readmission. Dual use occurs frequently in Veterans when those enrolled for VA care also receive care from non-VA providers or facilities. Evidence suggests that dual use is associated with increased healthcare utilization, costs, and worse health outcomes, including increased risk of death. Veterans receiving care at non-VA facilities risk potentially inefficient information exchange, duplicated medical tests and procedures, delays in care, and barriers to follow up. However, very little is known regarding reasons for dual use, predictors of dual use, and impact of dual use on important clinical endpoints in Veterans with HF. Objectives: Study objectives are to 1) understand why Veterans with HF use non-VA facilities for care; 2) identify patient, provider and systems level predictors of dual use in Veterans with HF; and 3) design and evaluate potential interventions focused on addressing dual use and improving HF outcomes. Specific Aim 1: To characterize perceptions regarding access to VA and non-VA care, dual use, and HF care quality among Veterans with HF and VA/non-VA healthcare providers. Specific Aim 2: To determine patient-level and provider/systems-level factors associated with differential health-services utilization and outcomes among Veterans treated for HF. Hypothesis 1: Among Veterans with HF, patient-level factors including dual use, older age, minority ethnicity, rural residence, and multimorbidity will be significantly associated with higher rates of 30-day all-cause hospital readmission and 30-day all-cause mortality after adjusting for relevant covariates. Hypothesis 2: Among Veterans with HF, provider/systems-level factors including higher baseline HF readmission rates, higher measures of HF care quality, worse measures of discharge preparation, smaller facility size, lower number of HF specialists, and more complex hospital case-mix will be associated with higher rates of 30-day all-cause hospital readmission and 30-day all-cause mortality after adjusting for relevant covariates. Specific Aim 3: To integrate data from secondary data analyses and key stakeholder interviews to facilitate the design and formative evaluation of interventions focused on reducing unplanned and potentially preventable HF hospitalizations among Veterans. Methods: For Aim 1, we will conduct semi-structured interviews using grounded theory to explore perceptions of access to care, dual use, and HF care quality. For Aim 2, we will merge VA/Medicare data for Veterans with HF in SC with comprehensive ED/hospitalization data from the SC Office of Research and Statistics as well as hospital data from American Hospital Association and quality data from CMS. For Aim 3, data from Aims 1 and 2 will be synthesized and used to design novel programs to reduce avoidable HF hospitalizations and readmissions. Finally, in response to calls for formative evaluation in intervention planning, we will conduct focus group sessions with patients and providers to assess the feasibility and acceptability of planned interventions in preparation for future grant proposals.